The Coronavirus Is More Than Just a Health Crisis

National leaders are leaning on experts to help deal with the outbreak, but the really difficult decisions are not medical. They are political.

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Even populists need experts, it turns out.

This was the message, at least, from the British government this week as it published its plan to tackle the coronavirus outbreak. At a press conference, Prime Minister Boris Johnson, flanked by his chief medical adviser, Chris Whitty, and chief scientific adviser, Patrick Vallance, sought to reassure the public that the country was well equipped to deal with the virus. In the likely next stages of the crisis, Johnson said, the government would follow the science.

The irony of the moment was not lost on critics who lambast Johnson as a charlatan who duped the country into Brexit with a series of lies about what it entailed while actively disparaging the “experts” who warned voters not to take the risk. Michael Gove, a cabinet minister who is one of Johnson’s closest allies in government, declared during that campaign, “The people of this country have had enough of experts from organizations with acronyms saying they know what is best, and getting it consistently wrong.” Now in power, Johnson will turn to those very experts to ensure that the crisis originating in a faraway land does not turn into one at home.

Yet there is a deeper irony still. Regardless of Johnson’s alleged double standard, experts cannot resolve this crisis, a fact that the scientists themselves explained at the press conference: The challenges of dealing with an outbreak of this scale are not technocratic but political, and decisions must be made in a fog of uncertainty.

Standing beside Johnson, his two advisers spelled out the reality, telling reporters that it was not simply a question of ordering the country to do whatever seemed safest—the social cost of draconian measures needed to be weighed as well. If schools were closed, for instance, doctors and nurses might have to take time off work to look after their own children, undermining the health service’s ability to cope. If older people are asked to avoid contact with others, how do their families ensure that they do not become socially isolated in the process? And what about the poor? Not everyone can work from home, so the cost of forcing people to do so would not fall equally. Temporary employees paid only for the hours they work would lose far more of their income than those with permanent contracts. Should the lowest-paid people in society really be expected to bear a higher burden for a national plan designed to protect everyone?

An outbreak like the coronavirus reveals the priorities and values of a society, and how long it can cope without the freedoms it’s accustomed to. Here in London, the government acknowledges that its own power is limited, and that it may have only a small window to impose curbs on a population unused to even basic state restrictions.

The first task for governments hoping to lead their countries calmly through the challenge might be to level with the public about this basic fact: that the puzzle of how to respond to COVID-19, the disease caused by the coronavirus, is not solely a scientific one, but a social and political one requiring widespread buy-in.

Take, for instance, a report in The Times of London on the British government’s plans claiming that ministers and officials were “considering the trade-off between allowing an acute outbreak, from which the economy would rebound more quickly, and trying to save more lives by imposing restrictions on mass gatherings and transport.” This is the ugly reality of government. As Stewart Wood, once an adviser to former Prime Minister Gordon Brown and the former Labour Party leader Ed Miliband, put it, such questions are exactly “the kind of grave utilitarian calculus we both absolutely need the crisis-planning part of our Government to be thinking about [and] absolutely need our Government not to discuss.”

In Britain, decisions of life and death are routinely considered by an institution called the National Institute for Health and Care Excellence, a body of experts that uses scientific evidence and data to evaluate whether medical interventions—operations, scans, drugs, therapies, or anything else—constitute “value for money” and should be made available via the National Health Service. If an intervention is deemed too expensive, even if it has some health benefits, such as prolonging life or easing pain, it will not be made available to the public, because that money can be better spent elsewhere. This is medical rationing by experts: finding the best way to distribute the finite pot of government money allocated for health care.

The reality, though, is brutal. To decide what is considered “value for money,” the institute uses formulas that measure the length and quality of life added by a medical intervention—“quality adjusted life years,” or QALYs. Each QALY is equal to one year of life in perfect health. Generally, the institute considers medical interventions costing £20,000 to £30,000, or about $25,000 to $38,000, per QALY gained to be cost-effective. Interventions costing more than that might not be sanctioned. In effect, then, the government has already placed a cost on life.

The problem, as Wood explains, is that resources are finite and burdened by competing demands. In dealing with COVID-19, the government can’t simply stop addressing everything else, like cancer, flooding, crime, or, of course, Brexit. And while debates that weigh economic considerations against people’s health are uncomfortable, all governments rely on economic growth to fund public spending. In other words, decisions about how to contend with the coronavirus must weigh the wider economic impact, because in the end, the economy will affect the government’s ability to keep people alive.

Over the next few months, the challenge for Johnson—and every other leader of a democratic country—is to convince the public that he is making reasonable, fair, and equitable decisions in the short term and striking the right balance among the country’s social, medical, and economic interests in the long term. The challenge is leadership.

Henry Kissinger once said that the difficulty of leadership is that, by design, all the easy decisions have already been made before they can reach the prime minister’s or president’s desk. The tough calls are all that’s left. “Real dilemmas are difficulties of the soul, provoking agonies,” he wrote. Many decisions faced by leaders are between two sets of evils; the skill is to pick the lesser.

The dilemma for Johnson is simple: How much time, money, and social upheaval should be spent saving lives from COVID-19? He will have to make this decision in the dark, weighing reasonable expectations of what will happen if he does or does not act in certain ways. He will be presented with scenarios that consider crime rates, drops in consumer spending, job cuts, tax losses, and strains on a health system dealing with other illnesses—as well as deaths from COVID-19.

Kissinger explained the dilemma of leadership: “The most difficult issues are those whose necessity you cannot prove when the decisions are made. You act on the basis of an assessment that in the nature of things is a guess, so that public opinion knows, usually, only when it is too late to act, when some catastrophe has become overwhelming.”

Johnson, then—and U.S. President Donald Trump and French President Emmanuel Macron and German Chancellor Angela Merkel—will be judged in hindsight for decisions taken without that privilege. Did he overreact or underreact? the public will ask. Did he calm a volatile situation or induce panic? Did he show leadership or reveal a lack of it? Is he up to the job? Faced with trying to ensure public confidence in his leadership, Johnson’s first reaction was to turn to experts. Those experts immediately threw the ball back to him.